Provider Demographics
NPI:1487953469
Name:NAYAK, SHIVALI (DDS)
Entity type:Individual
Prefix:DR
First Name:SHIVALI
Middle Name:
Last Name:NAYAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 EASTBROOK DR STE A-103
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5705
Mailing Address - Country:US
Mailing Address - Phone:720-903-0558
Mailing Address - Fax:
Practice Address - Street 1:3221 EASTBROOK DR STE A-103
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5705
Practice Address - Country:US
Practice Address - Phone:970-484-4102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-103711223G0001X
CODEN.000103711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86855867Medicaid
CODEN.00010371OtherCO DENTAL LICENSE